Iron supplement for children without dyes, fillers or preservatives. Here’s what I found and what I did.
At six months of age my son was diagnosed with very low iron, low hemoglobin and low ferritin. My sweet child had so many issues that by this time we were already on an all organic diet, no processed foods and certainly no dyes or preservatives. The pediatrician’s prescription was very by the book – RX Choice Ferrous Sulfate Drops. One look at the ingredients that contained sorbitol solution, most likely GMO sucrose, and likely GMO citric acid, alcohol, chemical sodium bisulfite, including synthetic natural and artificial lemon flavor and I was searching for a better option.
I immediately consulted an MD but also a homeopathic pediatrician (that did not take insurance by the way) and was instructed to go to Whole Foods and get chelated iron tablets; preferably in encapsulated powdered form so I can mix it in apple sauce. I asked several times if iron was, well, iron… Could I mess this up in any way? I will simply say that I do not think anyone has asked a question like that. Ever. When I asked about duration of iron supplementation I was met with a guess, yes a ‘guess’ of 30 days. I began my research.
THE BASICS
Breast milk does contain a small amount of iron that is highly absorbable but the amounts are not sufficient for an infant approaching 6 months.
- Full term infants typically have enough iron stores until about 6 months of age.
- Pre-term infants could develop anemia as early as 4 months.
- 20.1% of children in the 0 – 4 age category in industrialized countries are estimated to be anemic.
- 22.7% of pregnant women in industrialized countries are anemic.
- Some, like India estimate that 74 %of children aged 6-35 months are anemic.
- Vegetarians are more likely develop iron deficiency anemia because meat contains the more bioavailable heme iron vs non heme in plant based foods.
Anemia can lead to cognitive abnormalities, learning difficulties, and lower IQ. It also increases risk of heavy metal poisoning in children. “Absorption of other divalent heavy metals, including toxic metals such as lead and cadmium, is also increased.”(source)
Iron deficiency is very common it seems and the damaging effects are often irreversible. “In the United States, emphasis on the convenience of cow milk-based formulas led to decreased breastfeeding during the 1940s. This, in turn, resulted in cow milk anemia.” For toddlers, some experts recommend limiting cow milk intake to 20 ounces in 24 hours and instead diversifying the diet with a variety of healthy fresh foods.(source) Excessive cow milk intake in general as well as prolonged breastfeeding without supplementation with iron containing foods is also contributing to the national numbers.
DIAGNOSIS
First, if a finger prick shows low iron levels, be sure to ask to measure ferritin and a CBC panel that includes hemoglobin levels. “The serum ferritin level is the most specific biochemical test that correlates with relative total body iron stores. A low serum ferritin level reflects depleted iron stores and hence is a precondition for iron deficiency in the absence of infection .”(source) If ferritin levels are low, the next stage of the condition is low hemoglobin and finally iron-deficiency anemia. To read more and really get into specifics, click here and here. This helpful collection of normal pediatric laboratory values is very useful; I will also link to this article, it lists the Laboratory terms and definitions about half way down the page. It is beyond the scope of this post to go into complex details. A quick mention that a doctor is a great resource, causes of anemia vary and are not always simple but a competent pediatrician should be able to rule those rare instances out immediately.
INSTRUCTIONS
Iron supplements should be given on an empty stomach, 1 -2 hours before or after a meal for maximum absorption. Milk and other calcium containing products (tea, cereal, grains, flours, legumes, nuts and seeds) interfere with absorption and should be avoided at time of administration. Vitamin C rich foods may improve absorption but are not critical for supplements to work. These include citrus fruit, leafy greens, carrots, cauliflower, etc.
Taking iron on an empty stomach is not critical; iron consumed with a meal is better tolerated than when it is taken on an empty stomach, although the amount of iron absorbed is reduced. (source)
Side effects of iron supplements may present themselves as gray stained teeth, dark stools, abdominal discomfort and constipation. My son was severely deficient on a high dose but the only side effect we saw was the temporary gray staining on the teeth.
Dose. “The most widely cited dosing range in children is 3 mg/kg/day to 6 mg/kg/day of elemental iron divided 1 to 3 times daily.”(source) Please consult your pediatrician on correct dose for your individual case. The correct daily dosage may vary based on multiple factors including the laboratory levels. My son was very deficient so he was prescribed the maximum dose 30 – 45 mg per day based on laboratory results and weight. Iron overdose is VERY dangerous, do consult a pediatrician for correct amount.
Duration… This one was tough… “In response to treatment, the anemia will resolve first, but iron must be continued beyond the achievement of a normal hemoglobin concentration to ensure repletion of iron stores.” … “A positive response to treatment can be defined as a daily increase in haemoglobin concentration of 0.1g/dl from the fourth day onwards. Although the response in terms of haemoglobin concentration is virtually complete after two months, iron therapy should continue for another two or three months to build up iron stores.” (source)
Here lies a problem. The first round of supplementation was not enough, see below. Second time around, I was instructed to supplement for 30 days at least but insisted on a finger prick at 14 days and the appropriate levels were on the higher end of the normal range. I was also giving half of the dose as the bottle said it was highly bioavailable (a different iron form than pediatrician’s prescription).
My advice, be ‘that’ mom that does not listen and schedule a quick appointment with the nurse for a finger prick every 14 days of iron supplementation. Just to be sure…
SUPPLEMENT OPTIONS
Ferrous Bisglycinate
As per my second pediatrician’s instruction, I went to Whole Foods and bought Bluebonnet Chelated Iron. The dose was right and the capsules contained powder that I could take out and mix with something to be given to my 6 – 8 month old. There were no funky ingredients and I was happy with a clean iron supplement option. My son did not take it with apple sauce so I mixed it in berry jam and gave several teaspoons of freshly squeezed orange juice to help with absorption.
It was a turbulent time and I was looking for a descent pediatrician that would share my concerns. When I called the homeopathic pediatrician after 20 days to see if my son was OK with his iron levels, her response was “he is probably fine”. That response did not sit well with me but I did not dwell on it, after all, she was the doctor. A month or two passed and I scheduled an appointment with another pediatrician that has been mentioned several times in my circles. We came in for a meet and greet and did a finger prick just in case. My son was still anemic with levels slightly better than originally! I was livid. This was a strong reminder that just because someone is wearing a white coat, it does not mean they are right. And sometimes they are flat out careless. Iron levels should have been checked to determine if the round of supplementation was adequate.
The new pediatrician prescribed the same iron supplement with preservatives and synthetics as the first doctor. I showed him what I have been giving and was informed that ‘ferrous bisglycinate’, the one that was in the supplement I bought had not been studied in children. Turns out iron, is not well, just iron… There are different forms of iron and ferrous bisglycinate has only been studied in 40 children. I was again horrified but to my relief the study results were good; so good that I was questioning if the pediatrician read it before frightening me. In fact, the study found the ferrous bisglycinate was a better choice than ferrous sulfate. While both types of iron increased hemoglobin levels, only the children given ferrous bisglycinate iron chelate had significant increases in ferritin levels. “What this study suggested, in practical terms, is that when the iron was chelated to glycine and formed a bisglycinate molecule, enough of that source of iron was absorbed and metabolized to both correct the present and prevent future iron deficiency anemia in those infants.” (source) Considering bioavailability of the chelated iron is greater than that of ferrous sulfate, iron in the form of ferrous bisglycinate is a great choice. Whole Foods carries several brands including Bluebonnet Chelated Iron and I love the Designs for Health Ferrochel iron. Knowing what I know now, I would go with Designs for Health brand or Thorne Research brand; both do not contain questionable preservatives and have excellent reputation.
UPDATE 10/2016 Gaia Herbs carries an herbal liquid iron. Buy it here. Depending on necessary dose this supplement may or may not be feasible. In our case, with our necessary dose, we would need to give 6-7 teaspoons so crushing a pill and mixing with jam was easier. Gaia supplement contains honey; this supplement is NOT for children under 12 months of age. In addition, it contains herbs that may or may not be OK with a necessary dose. If 2 teaspoons are all that is necessary, this would be OK for an older child. If 6-7 teaspoons would be necessary, the herbs may bee too much. Consult your doctor.
Ferrous Sulfate – the more common choice
I have come to learn that there are more than a handful of iron forms, click here and here to learn more. Basically, we want the ferrous, easily absorbable version vs ferric form.
Ferrous sulfate is common and inexpensive. It is in most children’s iron supplements and is readily commercially available. After hearing my pediatricians concerns about ferrous bisglycinate, I began my search for something that was studied in children and was approved.
Floradix Floravital – Liquid or tablet form. Free of GMOs, preservatives, dyes, etc. Floradix contains yet another form of iron – ferrous gluconate. It is very similar to ferrous sulfate and has been studied in children. I did not notice any side effects from this supplments other than gray stained teeth. Certainly not attractive but my son took it with no problems or any constipation issues. What I did not like about Floravital is that the B12 vitamin is in cyanocobalamin form a synthetic form of methylcobalamin. Not gluten-free.
Spatone Pur Absorb* – 2018 Update. This is still my top choice. After a brief (and very disappointing break), Spatone went back to making plain iron rich water, without any additives or preservatives. Buy plain version here, or here. Apple flavored version contains preservatives (more of my thoughts on those below). Each packet of the plain version contains 5 mg of highly absorbable iron rich water. This is the cleanest iron supplement on the market suitable for children and pregnant women. No preservatives, no fillers, no flavors or any other junk.
Apple flavored version contains Vitamin C, apple concentrate and potassium sorbate. Daily recommended dose of vitamin C varies by age with upper limits of 400 mg daily in children 1 – 3 years. However, many suggest there are no side effects from too much C aside from diarrhea, but most will be eliminated with urine. (source) In my opinion for a child over 12 months this supplement should be OK. I am more concerned with the source of that vitamin C, which is highly likely from a genetically modified source (I have sent two emails inquiring to date with no reply). I also do not love the potassium sorbate. If you are on an all organic diet, free of GMOs, preservatives or dyes, this is not the supplement for you. If you are on a more lenient diet, Spatone Pur Absorb is an option.
*A quick note – if you choose this supplement – I administered this product in old formulation and because it is highly bioavailable, I only gave it for a week at half the dose. A finger prick two weeks earlier than I was instructed to come back revealed hemoglobin levels were back to normal with levels on the upper limit of ‘normal’. The clarity was off as I jumped from one supplement to the next in my search for the cleanest product. If I had to re-supplement and re-test, I would do a finger prick every two weeks to make sure the levels are where they need to be. And with several follow up appointments to make sure the levels stay at necessary levels.
Other honorable mentions
Molasses was suggested by many to increase iron. If the iron is slightly low and the recommendation is to eat iron rich foods, then molasses is a great option. 1 tbsp contains 15% of suggested daily value (so about 1.6 mg of iron based on recommended daily 11mg for children over 6m). However, if we are talking about a child that needs real supplementation, like my son who needed 30 – 45 mg daily, I would have to feed 19 tbsp of molasses daily just to get to 30 mg per day…
I loved the concept. It is an iron fish, quite literally that you add to your cooking pot. It releases iron into your foods. Not a bad way to add to the daily iron intake. “Charles et al 19 suggested that by drinking one litre (4.2 cups) of acidified water prepared by boiling with the Happy Fish for at least 10 minutes would provide approximately 75% of the daily iron required for women of reproductive age” … However while unlikely, “it is possible that the fish could be providing too much iron and cause iron toxicity”. And finally “Low levels of aluminum, antimony, boron, manganese and molybdenum were detected after boiling in distilled water…” (source) For most it will not be a problem but for the sensitive part of the population, including children on the spectrum, any additional heavy metals are not desirable.
Fortified Foods
As I was searching for the cleanest supplement, I got many suggestions to eat iron rich or fortified foods. (click here and scroll to table 2) There are cereals, flours and others. A child under one (some insist two) does not have proper enzymes to digest grains (Super Nutrition for Babies), while I did not know this when my son was that age, I did look at fortified oatmeal and others. They were so full of additives and synthetics that I just could not bring myself to feed my organically fed child those options. Others on the list looked tolerable but the amounts necessary to raise iron were unrealistic. In addition, only about 10% to 15% of dietary iron is actually absorbed. However, I do feel it is a good reference to have to include those foods in daily diet.
Aside from persona preference for unprocessed foods, this paper talks about foods fortified with ferrous bisglycinate being used to treat iron-deficiency anemia but I did not like the results. Some children did improve but some did not and I was not going to take a chance.
If I had to do it over again, I would stick with ferrous bisglycinate supplement of either with Designs for Health brand or Thorne Research brand. 2018 UPDATE: because Spatone now offers pure iron rich water, it would be my top choice for an iron supplement.
Do a finger prick every 14 days during supplementation and every 14-30 days after to make sure the iron levels stay where they need to; my son didn’t even blink at the procedure and was too busy exploring the pediatrician’s office. Iron overdose is serious and should not be risked even if there is a recommendation to be followed. This is not a one size fits all and sometimes we have to write our own protocol.
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